Your Opinion: How would you treat this case?
December 3, 2013
This case is presented by Dr. Donna Bereznicki
A 57 year-old new patient presented with what I think is external resorption on the distal cervical of tooth 35.
This particular tooth is asymptomatic, but requires a replacement restoration due to fracture of the existing amalgam. I am waiting for x-rays from the previous DDS which may or may not be available.
How would you treat this tooth? Thank you.
Take it out and place an implant. It looks like there is adequate bone. The prognosis of a tooth with external resorption is poor. I feel the most predictable result would be with an implant.
I’d replace the amalgam… use glass ionomer like Ketac at the most subgingival that I’d get to and wait and see. There’s no rush to extract an asymptomatic tooth. In a year or so if the tooth remains vital consider a perio referral for crown lengthening and decide from there.
Agreed. Extraction and Implant.
Exrraction and Implant.
What does it look like clinically? Abfraction lesion? How is the Perio?
My associate saw the case and in her opinion this is a very deep lesion – certainly not visible clinically.
With an explorer she was able to feel a catch on the distal of that tooth.
Patient has a past history of smoking. Presently a non-smoker.
Home care 75% effective
The distal of 35 probes 5mm
Rest of dentition some horizontal bone loss but probings within 4mm
This patient has not been to the dentist for 10 years.
the resorption appears significant, extending below the crestal bone. Crown lengthening would necessitate a lot of bone removal. The total treatment needed to save the tooth, surgery, endodontic therapy then restoration, is extensive and expensive providing an outcome with only a fair prognosis. I would favor extraction and an implant.
Surgical crown lengthening and an expensive crown on a questionable foundation may not be prudent.
That being said, I do agree with Gary about not rushing to extract an asymptomatic tooth (and I assume no apical pathology). I suspect the patient has no idea anything is wrong with the tooth and will be suddenly and unexpectedly be presented the most aggressive treatment (extraction). What is the harm in retaining the tooth, if your next step is extraction anyway? It is quite possible that this tooth can remain without symptoms or infection for a long period of time.
We may like to do the big treatment, but is it really in this patient’s best interest?
As for how to treat the tooth (rather than abandon the tooth as hopeless), I absolutely agree with Gary – Glass Ionomer – real self cure glass ionomer, NOT some resin modified or compomer, etc. Certainly in the area of the lesion, and as a base for the entire restoration. Some traditional composite on top wold be ideal for optimal wear resistance, etc.
If you have trouble placing the restoration, it might be worth doing a little envelope flap and a quick on the spot bit of bone removal (crown lengthening) on the distal. It is something that can be done in 2 minutes at the same time as the restoration… (plus time for a suture distal to the #35 if necessary) – not some separate big production crown lengthening procedure. It is, after all, a way to give the tooth a chance. Crown lengthening, full crown, and THEN an extraction and implant soon after is a sure way to upset your patient. So why not just do the implant now?? Because I think this tooth will sit in the mouth a long time before it ‘needs’ to be extracted. It’s been sitting there already, the patient “deprived” of an implant.
Wait until it is symptomatic, then extract, wait 6 weeks minimum, and cantilever a pontic off the #36; this treatment would not necessitate unnecessary tooth reduction due to the fact that #36 already has a crown that would just have to be removed, and, from experience and observation, 2nd premolars are good candidates for cantilevered bridges off of 1st molars.
If you go in there and excavate you may need to do a root canal, crown lengthening and crown or forced eruption with ortho allowing you to obtain a sound root/crown ratio.
Is all that cost effective vs extraction and implant on a long term prognosis? In my opinion either do no treatment and follow up every 4 months for a year or two if the tooth becomes symptomatic or there is some bone loss then extract and do implant.
I have treated a number of these cases with either extraction and implants, or restoration of the defect. Treatment depends on the severity of the defect. This defect looks small, and the tooth is likely salvageable. My recommendation is to save the tooth, however it will need flap surgery to restore the subgingival resorptive defect and endodontic therapy since communication with the pulp is almost certain at this time, even though it is asymptomatic, I say this from experience in treating these cases. Refer out if you are not comfortable completing the above treatment.
The resorption area on # 35 is below the bone. Long term it would be best to extract the tooth. I notice far too many Dentists consider implants as a primary response. I suggest we look at the quadrant where we have # 37 missing and # 38 on a mesial tilt. Tooth # 36 looks as if it has decay on the mesial under the TMS pin. This would be corrected when the crown is replaced.
The next problem is the mesial slant of # 38. The mesial can be reduced to allow for a bicuspid sized pontic. The distal wall may not provide enough retention. In most of these cases I prepare the 3 re molar as a normal crown and place a sleeve on the mesial as part of the 3 unit bridge. In a lot of these cases I place a horizontal screw to lock it all in a 4 unit bridge. I have had these in for over 40 years. Lots of luck.